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Charting By Exception (CBE)

CBE is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.

Key Elements of Charting By Exception (CBE)

  • Flow sheet: Examples include a graphic record, fluid balance record, daily care record, client teaching record, client discharge, and skin assessment record.
  • Standards of nursing care: Documentation by reference to the agency's printed standards of nursing practice eliminates much of the repetitive charting of routine care.

Bedside Access to Chart Forms

  • In the CBE system, all flow sheets are kept at the client's bedside to allow immediate recording.

  • Computerized Documentation: Electronic Health Record (EHR)

  • EHR was developed to manage the huge volume of information required in contemporary healthcare. It stores the client's database, new data, revised care plans, and documents client progress. Some institutions have a computer terminal at each client's bedside to enable the nurse to document care immediately after it is given.

Case Management

Case Management is a model that emphasizes quality, cost-effective care delivered within an established length of stay. It uses a multidisciplinary approach to planning and documenting client care. Using critical pathways helps identify the expected outcomes for each day of care. Variances are deviations from what was planned on the critical pathways, such as elevated temperature or impaired skin integrity.

Questions on Charting By Exception (CBE)

Correct Answer is D

Explanation

<p>Bedside documentation is the process of recording clinical information at the point of care, using paper or electronic formats.</p> <p>This method of documentation has several advantages, such as:.</p> <p>&bull; It reduces transcription errors and improves accuracy, as the information is recorded directly from the source and not from memory or notes.</p> <p>&bull; It allows access to multiple sources of information at once, such as electronic health records, lab results, medication orders, etc.</p> <p>&bull; It enhances communication and collaboration among health care team members, as the information is shared in real time and can be accessed by authorized personnel.</p> <p>&bull; It saves time and increases efficiency for the nurse, as it eliminates the need to leave the patient&rsquo;s bedside to document care or to transfer information verbally.This also allows more direct time with patients and improves patient satisfaction.</p>

Correct Answer is ["A","B"]

Explanation

<p>The names and contact information of the case management team are not part of the EHR, but rather a communication tool that facilitates coordination of care among different providers and organizations.</p>

Correct Answer is A

Explanation

<p>Discontinuing the critical pathway is not necessary or appropriate for a wound infection.The critical pathway is a guideline for optimal care that can be modified according to the patient&rsquo;s condition and needs.</p> <p>The nurse should follow the critical pathway as much as possible and document any variances.</p>

<p>It is too narrow and specific.</p> <p>Asking the client how well they understood their discharge instructions does not reflect the whole process of the case management model, which involves more than just discharge planning.</p> <p>It also does not measure the effectiveness of the care in t

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